PROPOSAL FORM ( The issue of this form is not to be taken as an admission of liability )

Transcription

1 Bajaj Allianz General Insurance Company Limited Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pune CIN: U66010PN2000PLC STANDARD FIRE & SPECIAL PERILS POLICY PROPOSAL FORM ( The issue of this form is not to be taken as an admission of liability ) Acceptance of this proposal is subject to the rules & regulations of All India Fire Tariff. The property is not covered until the proposal is accepted and premium paid. Agent Client Code DETAILS ABOUT PROPOSER 1. Name of proposer 2. Address of proposer Pin Code: Tel : (O) (Mobile): Fax : ( ): PUT A MARK WHEREVER APPLICABLE All the questions to be answered completely. Incase of shortage of space kindly enclose the information as an annexure : 3. Business of proposer 4. Policy to be issued in favour of (List of all the parties who have insurable interest including the financial institutions) 5. Location(s) to be covered (Full postal address with pincode) 6. Period of Insurance 7. Would you like to delete these perils from the basic cover? From To a. Storm, flood, tempest, inundation cyclone group of perils Head Office & Regd. Office : GE Plaza, Airport Road, Yerawada, Pune Tel. : (+91 20) Fax : (+91 20)

2 b. Riot, Strike, Malicious Damage C. Terrorism cover extension (It can be opted if RSMD is opted) 8. Would you like to cover Plinths & Foundation along with your buildings? 9. Add - On Covers Required as under a. Architects, Surveyors, & Consulting Engineers Fees (in excess of 3% of the claim amount) b. Debris removal (in excess of 1% of claim amount) c. Deterioration of stocks in cold storage premises i. Due to failure of electrical supply at terminal ends of electric service feeder due to an insured peril ii. Due to change in temperature assuring out of loss or damage to cold storage machinery in the insured's premises due to operation of insured peril d. Forest Fire e. Impact damage due to insured's own vehicles, fork lifts and like & articles dropped there from f. Spontaneous Combustion g. Omission to Insure additions, alterations or extensions h. Earthquake (Fire & Shock) i. Spoilage material cover j. Leakage and contamination cover k. Temporary removal of stocks l. Loss of rent m. Additional expenses of rent for an alternate accommodation n. Start-up expenses o. Molten material damage 2

3 10. Whether you have insured the same property with any other insurance company with identical coverage (If so, give details) 11. Whether Insurance cover was declined by any other company or imposed any special conditions (If is, give details) 12. Premium / incurred claim details for the past 36 months excluding the expiring policy period Premium Claims DETAILS ABOUT PROPOSER'S BUSINESS COVERED AT THE LOCATION 13. The Insured property is a. Dwellings, offices, shops, hotels etc. b. Industrial / manufacturing risks c. Storage outside Industrial/ manufacturing risks 3

4 d. Tanks / gas holders outside industrial/ manufacturing risks e. Utilities located outside Industrial/manufacturing risks 14. If used as shop, please declare whether the goods handled include any goods appearing in the list given below. If, whether the value of such stocks exceeds 5% of total value of stocks 1. Celluloid Goods, 2. Coir Loose, 3. Crackers & Fire Works, 4. Explosives of any kind, 5. Hay / Straw, 6. Hemp, 7. Jute Loose, 8. Matches, 9. Methylated spirits, 10. Nitro - Cellulose, 11. Oils / Ether/ Industrial Solvents and other inflammable liquids flashing at and below 32 Deg. C.( closed cup Test), 12. Paints with inflammable base having flash point below 32 Deg.C (closed cup test) other than in sealed tins or drums, 13. Varnishes having a Flash point below 32 Deg. C (closed cup test) other than in sealed tins or drums, 14. Disinfectant liquids and liquid insecticide other than in sealed tins or drums, 15. Vegetable fibres of any kind including Rayon Fibre 15. If used as warehouse / godown (located outside the factory compound) please give the list of goods stored 16. If used as an Industrial Manufacturing unit, state the details of products manufactured at the location proposed (detailed block plan showing various facilities to be enclosed) 17. If used as an Industrial Manufacturing unit, please state whether the factory is working or silent? 4

5 18. Fire Extinguishing Appliances installed a. List the various blocks and indicate the type of protection provided for each block. Please tick in the space below : Portable Extinguishers Trailer Pumps Fire Engine Hydrant System Sprinkler System Fixed Water Spray System b. Indicate whether annual maintenance contract for the appliances is in form 19. The basis proposed for insurance (Building/Machinery/Furniture Fixures & Fittings) a. Market Value basis b. Reinstatement Value Basis c. Whether escalation is required 20. Construction Details a. Please state material used i. Walls ii. iii. Floor Roof b. Height of the building Meters Floors c. Age of Building Less than 5 years years 5-15 years Above 25 years te : Buildings having walls and / or roofs of wooden planks/ thatched leaves and/ or grass/ hay of any kind / bamboo / plastic cloth / asphalt cloth/ canvas/ tarpaulin and the like are treated as Kutcha construction 21. Building wise values (Please include the 'Kutcha' building also in this list and give individual value in Rs. against such buildings Description of block Age (Yrs) Height (mts) Construction Pucca/Kutcha Building Including plinth Machinery accessories Sum insured Rs. F&F, Office and other equipments Stocks and stocks-in process** Other Property to be insured specifically Rs. Rs. Rs. Rs. Rs. Total te : ** Indicates those stocks which are covered on normal basis and do not fall under Serial. 23 A,B,C, and D below 5

6 22. Special coverage for stocks only :- Please tick in the box below and give the amount to be insured against each A. On Floater Basis : Stocks at various locations (Process blocks, warehouses/ godowns and /or in open etc.,) can be covered on floater basis under single Sum Insured Locations ( Postal Address with Pin code ) B. On Declaration Basis : Stocks which fluctuate in value can be covered on (monthly) declaration basis. Locations ( Postal Address with Pin code ) te: Minimum Sum Insured is Rs. 1 Crore, and policy not issued on short period basis. Stocks in process & stocks stored at Railway sidings cannot be covered. C. On Floater Declaration Basis : Stocks which fluctuate in value as well as stored at various locations under single Sum Insured can be covered on (monthly) floater declaration basis. Locations (Postal Address with Pincode) te: 1. Minimum Sum insured is Rs. 2 Crores 2. Stocks in process & stocks stored at Railway sidings cannot be covered. D. Stocks stored in open (located outside the factory compound) Detail of stocks stored in open : Locations (Postal Address with Pincode) 6

7 E. Tank Farm and Gas Holders (located outside the factory compound) Detail of stocks stored in open Locations (Postal Address with Pincode) 23. Would you like to avail discounts for voluntary deductibles If answer is yes, indicate the choice of deductible amount Rs. DECLARATION BY INSURED I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and I/We hereby agree that this declaration shall form the basis of the contract between me/us and BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED. If additions or alterations are carried out in the risk proposed after the submission of this form, then the same would be conveyed to the insurers immediately. I/we have read and understood the Privacy Policy of your Company and I hereby unconditionally agree and bind myself to all terms and conditions of your Privacy Policy, as amended, from time to time. Date : Place : Signature of Proposer & Seal of the Company Recommendations of Agent : The following is the copy of section 41 of the Insurance Act 1938 PROHIBITION OF REBATES 1. person shall allow or offer to allow either directly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of the premium shown in the policy nor shall any person taking out or renewing or continuing a policy except such rebates as may be allowed in accordance with the published prospectus or tables of the insurer. 2. Any person making default in complying with the provision of this section shall be punishable with a fine, which may extend to five hundred rupees. 7